Uterine rupture — MSF Essential obstetric and newborn care — Médecins Sans Frontières 2026

MSFClinical guideline (chapter)Current edition

From Essential obstetric and newborn care › Chapter 3: Bleeding during the second half of pregnancy · Médecins Sans Frontières, Current online edition, 2026

Clinical guidance on prevention, diagnosis and emergency surgical management of uterine rupture for maternity care providers.

In one sentencePrevent uterine rupture with partograph monitoring and rational oxytocin use; diagnose by persistent abdominal pain and shock; manage with immediate laparotomy, repair or hysterectomy.

Issuer: Médecins Sans Frontières
Edition: Current online edition, 2026
Audience: Obstetricians, midwives, anaesthetists and emergency physicians in CEmONC and BEmONC facilities
Evidence: Expert consensus based on MSF field experience
Reviewed: 23 Oct 2026 · GMJ

Read the original on MSF Whole guideline (PDF)

Summary by GMJ Guidelines Desk•Reviewed by Prof. Giorgi Pkhakadze, MD, MPH, PhD•Record updated 23 Oct 2026•Next check Apr 2027

What this guideline says

GMJ summary

This section of MSF’s Essential obstetric and newborn care guideline addresses uterine rupture, a tear in the uterine wall occurring most commonly during labour. The guideline emphasises prevention in CEmONC and BEmONC facilities through careful labour monitoring with partograph and vigilant, rational use of oxytocin and prostaglandins.

Clinical diagnosis focuses on recognising impending rupture (maternal agitation, severe persistent abdominal pain, Bandl’s ring) and complete rupture (shoulder-tip pain, hypovolaemic shock, cessation of contractions, foetal distress or death). Emergency management requires immediate laparotomy with caesarean section, fluid resuscitation and blood transfusion, with decision on uterine repair versus hysterectomy based on rupture type, patient condition and presence of infection.

The guideline provides detailed surgical technique including incision type, bladder integrity checking, edge trimming before repair, and indications for subtotal hysterectomy. Given high recurrence risk, bilateral tubal ligation may be indicated with patient consent, discussed preferably before surgery.

Key points

For clinicians — doses and thresholds as stated in the guideline

Uterine rupture can be reduced through labour monitoring with partograph and vigilant, rational use of oxytocin and prostaglandins
Grand multiparas (5 deliveries or more) and women with prior uterine surgery (caesarean section, myomectomy) are at increased risk
Impending rupture signs: maternal agitation, severe abdominal pain persisting between contractions, abdominal guarding, often Bandl's ring
Complete rupture signs: shoulder-tip pain, hypovolaemic shock, cessation of contractions, slow or absent foetal heart tones
Emergency management: insert 2 IV lines (16-18G catheter) with Ringer lactate, insert Foley catheter, immediate laparotomy with caesarean section
Check bladder integrity during surgery; if injured, continuous suture in one or two planes with urinary catheterisation for at least 7 days
Perform subtotal hysterectomy with ovarian conservation if uterine infection, extensive rupture with severe bruising, or repair not possible
Bilateral tubal ligation may be advised given recurrence risk in subsequent pregnancies; patient consent required, ideally discussed before surgery

From the guideline

Verbatim

“In a CEmONC or BEmONC facility, uterine rupture can be reduced by monitoring the progress of labour with partograph, and vigilant, rational use of oxytocin and prostaglandins.”

— Médecins Sans Frontières, Uterine rupture — MSF Essential obstetric and newborn care, Section 3.3 (2026)

Editor’s perspective

Why this matters for Georgia and the region

Prof. Giorgi Pkhakadze, MD, MPH, PhD

Editor-in-Chief, Georgian Medical Journal · Chair, Public Health Institute of Georgia · WHO consultant, health and migration

As Editor-in-Chief of the Georgian Medical Journal and Chair of the Public Health Institute, I recognise that uterine rupture represents a preventable maternal death in settings where emergency obstetric care functions well. Georgia's institutional delivery rate exceeds 99%, yet the critical element this MSF guideline highlights—vigilant partograph use and rational oxytocin protocols—requires continuous clinical audit in our maternities. I would stress to Georgian obstetricians the importance of recognising Bandl's ring and persistent inter-contraction pain as surgical emergencies requiring immediate laparotomy, not conservative management. The realistic challenge is ensuring that every facility offering labour induction or augmentation has both the partograph discipline to prevent rupture and the surgical capacity with blood bank access to manage it when prevention fails.

ORCID 0000-0001-7609-4515 · Perspective written for the GMJ Guidelines Library, 23 Oct 2026

Applicability

Georgia and the South Caucasus

Uterine rupture remains a critical obstetric emergency in Georgia and the South Caucasus, where institutional delivery rates are high but access to comprehensive emergency obstetric care varies between urban and rural settings. Georgian maternal health programmes would need to ensure that CEmONC and BEmONC facilities have functioning partograph systems, standardised oxytocin protocols, and capacity for immediate laparotomy with blood transfusion. Particular attention should be given to monitoring grand multiparous women and those with previous caesarean sections, as classical caesarean section rates in the region’s recent past may place some women at higher risk. Emergency referral pathways between lower-level facilities and surgical centres require clear protocols and functioning ambulance systems to achieve the rapid intervention this guideline demands.

Questions this guideline answers

Quick answers

What are the main risk factors for uterine rupture?

Obstructed labour, grand multiparity (5 deliveries or more), excessive use of uterotonic drugs (oxytocin or misoprostol), and prior uterine surgery including caesarean section (especially classical), uterine perforation, or myomectomy.

How do you recognise impending uterine rupture before it happens?

Look for maternal agitation, increasingly severe abdominal pain that persists between contractions with abdominal guarding, and often Bandl's ring (which may initially resemble a distended bladder), a sign of obstructed labour.

What immediate steps should be taken when uterine rupture is suspected?

Insert 2 IV lines (16-18G catheter) and administer Ringer lactate, measure heart rate and blood pressure, insert a Foley urinary catheter, and proceed immediately to emergency laparotomy with caesarean section and fluid replacement with blood transfusion in most cases.

When should hysterectomy be performed instead of uterine repair?

Perform subtotal hysterectomy with ovarian conservation in the event of uterine infection, extensive rupture with severe bruising around the wound, or when suture repair is not possible. Keep surgery as brief as possible as these patients are often in poor general condition.

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Uterine rupture — MSF Essential obstetric and newborn care

What this guideline says

Key points

From the guideline